Complexities of Diabetes w Dementia

Wilted Daughter

90 yo mom with diabetes spanning over years is prescribed (2) meds for high blood pressure, one of which is said to be a high dose. Infrequent fainting which is now frequent (7 mos apart) results in ER/Hospital/Rehab/VN/PT...(3xs since 8/21).

Last incident 10/6 insulin was added (33 units daily) with no home health care to teach how to admin insulin...I knew NOTHING. Elder Services paid for (1) RN visit who is now communicating with the DR. After repeatedly informing RN that mom complains of weakness/dizziness when her glucose level is in the mid to low 100s, I learned yesterday to hold insulin when #s are below 140 because she is frail (She's been frail for years...DR in rehab is her primary) ????  A few days home learned there is no insulin/needle refills when script is called in for needles they are different...you have to remove 2 caps instead of 1...I was injecting mom with 1 cap on for a few days before realizing (Only provided 1 instruction at the hospital for injecting insulin using a 1 cap needle). This is the same DR who informed high A1C/Glucose is expected in seniors at the time A1C  8+ and increased to 10+ (spring to fall same diet but removed diabetes meds every time she goes to the hospital/rehab...never added back, changed, lightly monitored after discharge). 

Contacted Hospice but without prognosis of 6 mos no services. I've switched back to basic Medicare (all home health agencies in the area will not bill her Medicare Advantage plan). When I look at mom, I see her confused/clinging to life...when I just want to throw in the towel.

M1

WD:  This is going to sound radical to some, but I would think hard about not giving her insulin.  If you can give her oral medicines that keep her out of ketoacidosis (which is pretty rare in type 2 diabetics anyway)--or even consider no medicines at all if you can control her diet--that's what I would do, and I simply wouldn't check her blood sugars.  Or her blood pressure, for that matter.  It clearly sounds like it's time for comfort care, and I doubt if insulin is contributing to her comfort.  You have to ask, what are you treating here?  These questions get very hard in the very elderly.  If you had a really good primary care or hospice doc, they might be able to help you think through this.  Not easy, I know.

Wilted Daughter

Thank you. Comfort care is my goal...and I need to make that clear to all. Insulin was added due to dangerously elevated #s but I've noticed that she appears better when #s are 166 to 240s. I don't feel insulin should be long-term at the current dosing, if at all and will discuss next week.

It appears that treatment is reactive to fainting (which causes trips to ER...) her meds have this side effect. I feel we are simply chasing a remedy for old age/health issues when we need to also focus on quality of life and balance. 

Again, thank you

Rick4407

Hello WD, I know nothing about type 2 diabetes and can add nothing there.  

I believe M1's advice about "seeking quality of life and balance" is the very heart of what I hope to provide for my DW.  It's a hard goal to accept.  Rick

M1

I'll add one more thing for you to challenge: who is defining what "dangerously high" levels are? Was she symptomatic? I'd bet not. So why was it dangerous? omeone is just reacting to a number that is meaningless in this setting. That's why I'd really think hard about not checking her blood sugars at all. They are chasing their own tail. But it's very hard to get people to think this way. How you react for a 40 yo is not the same for a 90 yo at the end of life. 

good luck with this.

JDancer

High blood sugar leads to long term damage-eyes, kidneys, nerves, etc. Is this a concern? Sometimes very high blood sugars combine with ketoacidosis which can be a medical emergency. Is this a concern? Low blood sugars can lead to loss of consciousness and even coma. 

Personally, I wouldn't give insulin to my LO with dementia. For me, low blood sugar would worry me more than high sugars. And long term wouldn't be an issue, for me.

Caring for LOs with dementia involves difficult decisions on an almost daily basis. Whatever you decide is best for you and your LO is the right decision.

Iris L.

I agree with M1.  Blood sugars of 140-200 are not dangerously high.  On the other hand, overdosing on insulin is very dangerous. I agree with comfort care.  

I would even consider monitoring urine sugar to avoid too many finger sticks and venipunctures.  If she is spilling sugar in her urine, you could confirm with a blood draw.  Or not, if you decide to forego blood draws altogether.

Iris

Wilted Daughter

Thank you all. 

The long-term effects of diabetes have long ago eroded medical conditions (i.e. liver, heart, eye sight...). Her blood sugar levels were consistently between 306-406 weeks prior to fainting(she did not complain, but I noticed change in her mobility). She does not complain when #s are high but does complain of weakness, etc. while taking insulin and #s are considered to be within ADA normal range.

Recently learned there is a "hold #" if self-testing falls below this # insulin is not administered. (over past few days her insulin intake has decreased from 4x's daily to 1 or 2 x's). She does not like/nor want to take insulin and I'm uncomfortable administering. At latest ER/Hosp trip they treated fainting/high blood sugar (A1C) 10+...it's all systematic and varying. Trip before that it was fainting/low blood pressure and prior to that fainting/ low heart rhythm (pace maker implanted). Hospitalization is increasing/occurs due to fainting and treatment is centered around a possible cause (dehydration, low/high this or that). ALL her meds list side effect(s) dizziness/fainting but that doesn't seem to be a priority for change. 

Currently, I am addressing the need for hospice or palliative care with special focus on best quality of life (comfort/dignity/reduced pain). Aggressive treatments of diabetes, etc. is not proven to be helpful or reduce mom's hospitalization. When she faints/hits her head it takes time of the clock, so we need a treatment/end game plan. 

Best wishes to you all and your families! May you all stay strong while caring for LOs and remember someone loves you, too!!

aconite

DH has been insulin-dependent for a long time - before the onset of AD. 

I do have some thoughts to share based on that experience.  

 - In the course of managing his diabetes, as we worked to bring his blood sugar levels down, he felt shaky/unwell when his levels approached "normal".  It took some time of lowering his levels for him to feel ok when his blood sugar levels were at 100.  (And to do so, there were several low blood sugar occurrences - this was pre AD and when he could manage himself.  I couldn't do that now.)  

- A1C measures blood sugar levels over a period of time, so day-to-day changes aren't reflected in that measurement for some time.

- Maybe only a long acting insulin once a day along with diet would be easier to manage.  I could not tell from your post if you're doing only long term or if you're doing insulin with meals.

- We have switched to a continuous glucose monitoring system which helps me to better manage DH's blood sugars.  But he is in the early stages of AD, has had diabetes for a long time, and we still do insulin with meals.  At this point in time, he doesn't fiddle with the attached monitor.  But that may become a concern as his AD progresses.

As others have suggested, I question attempting to aggressively treat her diabetes.

  

trh5246

I am looking for some external advise on when a person with dementia should be moved to a 24/7 care facility.  My mom is 82 years old, has diabetes, dementia, and AFIB with slow heart contraction speed.  She is currently on medications for heart, and takes insulin 4 times a day.  Fast acting (5 units) with meals, and 20 units extended release Lantus before bed.  My family and I have been caring for her by going over for Breakfast, Lunch, Dinner and Evening meds since late July.  In the last month she has done a few things different.  Left burner of stove on when she fixed herself breakfast before we got there.  Taken trash out on her own, managing a stair to the garage that she has fallen on before, and wearing the same clothes and not showering until instructed to do so.  Her appetite has lessened as well.  When do you know if/when it is time to move mom to Assisted Living?  My siblings all have varying ideas, most of what their perception is of the care my mom needs from a safety concern.  I'm blessed that we are all trying hard to keep moms best interests in mind, and not our own, so far.

Olly_Bake

trh5246 - you may want to start your own post.

Wilted Daughter, have you run all moms meds through the drug interaction checker on drug dot com? I don't care who prescribes what, they go through the drug checker. Just did last week for hubby. Found out a couple of his meds could not be taken during the day with his pain management med.  

Two blood pressure pills for a 90-year old with one you believe is considered a high dose. Seems much. If I were you, I would consider tapering down to one blood pressure pill if you can figure out which one controls best. Maybe one week just administer one kind and leave the other off. Then the following week try the other. Stick with the one that controls best. My LO (dad) does one heart pill (carvedilol) daily. 

His primary passed on to home health that we should not be concerned for BP unless under 90/50 or as high as 160/100. He stays around 142/70.

100 for blood sugar is too low for moms frail body and she probably does not eat the same as in her younger days. I refuse insulin for him due to what you state your mom states and glad his primary agrees. When he had to go into the hospital it is out of my control as they claim it is protocol. But trust what your mom is saying about how she feels once administered. 

We do one Januvia 50mg daily. He runs between 125 and 150. We have not seen him go over 150 in over a year now even with his daily coffee and eating cookies here or there during the day (vanilla wavers, macaroons, or graham crackers. He will not budge on those treats.

His primary passed on to home health that we should not be concerned for his type 2 unless it starts being over 200 daily not here or there.

We still test BP and sugar once a day. I have not been able to graduate to not checking

Wishing you and your mom well!!!